Health-Seeking Behavior of Urban Poor Communities

Philippine Institute for Development Studies

Health-Seeking Behavior of Urban Poor Communities Olympia Malanyaon DISCUSSION PAPER SERIES NO. 95-13

The PIDS Discussion Paper Series constitutes studies that are preliminary and subject to further revisions. They are being circulated in a limited number of copies only for purposes of soliciting comments and suggestions for further refinements. The studies under the Series are unedited and unreviewed.

The views and opinions expressed are those of the author(s) and do not necessarily reflect those of the Institute.

Not for quotation without permission from the author(s) and the Institute.

June 1995 For comments, suggestions or further inquiries please contact: The Research Information Staff, Philippine Institute for Development Studies 3rd Floor, NEDA sa Makati Building, 106 Amorsolo Street, Legaspi Village, Makati City, Philippines Tel Nos: 8924059 and 8935705; Fax No: 8939589; E-mail: publications@pidsnet.pids.gov.ph Or visit our website at http://www.pids.gov.ph

Baseline

Policy Research for Health Care Financing Reforms DOH - PIDS Joint Project

SPECIAL

THE

OLYMPIA

QUIMBA

BENEFICIARY

URBAN

MALANYAON,

EDILBERTO M. CONCEPCIONI M.D. HealthDev Institute Ateneo de Manila University Loyola Heights, Q.C.

GROUP:

P O O R

M.D.

..........

i

HEALTHDEV

OLYMPIA

INSTITUTE

.........

RESEARCH

QUIMBA MALANYAON, Project Coordinator

EDILBERTO M. CONCEPTION, Asst. Project Coordinator

TEAM

M.D.

M.D.

MA. CRISTINA DE CASTRO MA. GINA V. CONSTANTINO Project Facilitators

May 1994

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TABLE

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OF CONTENTS

Executive Summary ...................................................... •................................................................................... 1 I, Introduction ...............................................................................................................................................

3 II, Statements of the Problem and Objectives ................................ _............................... _.._ ............. ............ 5 III, Study Framework .............................................. ;...................................................................................... 6 Definition of Terms ...................................................................................................................................

8 IV. Methodology ................................................................................................................................ :............ 9 V, Findings and Discussion .......................................................................................................................

13 A, Profiles of the Communities ........................................................................................................... 13 B. Health Attitudes, Perceptions and Health-seeking Behavior ................... ,............................. .... 19 C, Health Care Financing ......................................................................................................................

24 D, Factors that may Facilitate or Hinder the Implementation of an HCFS ........................ L.......... 27 VI, Summary and Conclusion ..................................................................................................................... 31 References Appendices LISTOF

TA.B.LES

A1.

A2, A3.

A4.

A5.

A6.

A7.

A8.

A9, A10.

All. A12.

APELO CRUZ Sex ..................................................................................................................................................

14 Age ........ ................. i.......................................................................................................................

14 Educational Attainment ................. ............................................................................................ 14 Household Members ....;..: ........................................................................................................... 14 Average Monthly Income ................................................. ;.................................................. ....... 15 Average Expenditure ..................................................................................................................

15 Organizations Involved In ....................................................................................... .................. 16 Assistance Received from Organizations ................................................................................ 16 Individuals Usually Consulted ................................................................................................. 21 Health Attitudes, Perceptions, Practices ................................................................................ 22 Sources of Funds for Consultation ........................................................................................... 25 Sources of Funds for Hospitalization ............................................................. _................. ........ 26

B1.

B2.

B3.

B4.

B5.

B6.

B7.

B8.

B9.

B10.

Bll. B12.

BAGBAG Sex ................................... ............................................................................................................... 14 Age ................... :.............................................................................................................................

14 Educational Attainment ............................................................................................................. 14 Household Members ................................................................................................................

14 Average Montrd 7 Income ..................................................................................................... ft... 15 Average Expenditure ..................................................................................................................

15 Organizations Involved In ......................................................................................................... 16 Assistance Received from Organizations ................................................................................ 16 Individuals Usually Consulted ................................................................................................. 21 Health Attitudes, Perceptions, Practices ..L.............................................................................. 22 Sources of Funds for Consultation ........................................................................................... 28 Sources of Funds for Hospitalization ....................................................................................... 26

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EXECUTIVE

SUMMARY

T his study, employing the participatory action research (PAR) approach, sought to determine the socioeconomic conditions in relation to health care of the urban poor communities of Apelo Cruz, Pasay and Bagbag, Nova Hches. h3_eekLD_g to answer this problem, this study looked into the demographic characteristics of the two communities, their perceptions and attitudes towards health care and their health-seeking behavior, and their willingness and readiness to participate in risk-sharing on health maintenance.

Using random and pur t)osive sampling 201 individual interviews (100 in Apelo and 101 in Bagbag) and six focus group discussions (th.ree for each community) were conducted by the trained local research teams with the assistance of the project facilitators. A preliminary socialinvestigation was conducted by the project facilitators prior to the selection of the communities to be studied and of the local research team members.

The research team of Apelo Cruz was composed of seven members while the research team of Bagbag, of eight members.

The members were mostly the community leaders themselves.

The research teams participated hi formulating the research design and h_trumertts, gathering and analysis of data, and presentation of results to the communities.

The findings revealed that the two urban poor communities studied had household heads who were relatively young, had reached or finished highsch0ol, and had been in the area for more than 3 years with no definite plato of _rhigrating to another place. With an average family of four, the average montt_dy income was P4,000 with average montlxly expenditures of P4,500.

Health was a priority concern among the people. • The people's attitude towards hea!th was more crisis-oriented, curative rather than prevea_tive. They expressed more confidence in tile kalowledge and expertise of medical professionals rather than in traditional healers or "herbolaryos".

They would go to great lengths - selling or pawn.trig valuable properties or borrowing money even at usurious rates, just to finance their health needs.

The respolldents also expressed preference for private medical facih'ties and personnel over government ones given the perceived inadequacy and incompetence of the latter. Several active orga.nizations had been assisting the commmdties in their problems such as on land tenure and medical expenses.

The respondertts expressed wil!ingTLess to participate in a health care financing scheme (HCFS) provided the terms were acceptable to them. However the sources of funds which they cited to pay for an agreed upon premium were rather unrealistic - windfall income from small businesses or donations from the goven'u-nent and private institutions.

Nevertheless, some were willing to cut down on their vices Sl.tcll as smokh_g so that !hey could have money to pay for the premium.

Factors identified that could facilitate the implementation of a successful HCFS h_cluded: the "p aluwagan" system pa trortized by the people; the value ofamor propio; positive attitude towards -

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health and medical doctors and utilization of health care facilitites, and Medicare; the people's Willh_gness to work for services rendered them; the extended family prevailing among the people; and the existing organizations in the communities.

On the other hand, the factors identified that could hinder the HCFS implementation were: the people's crisis-orientation towards health; misconceptions about rational health care; lack of _nfider_ce in govenu'nent health persm'u_el and facilities; ideological leaning of some existing organizations in the communities; lack of technical skills and capability of the people; lack of regular source of income; and poor livfi_g conditions.

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I. INTRODUCTION

1_ oor health remains a leading problem among the count-ry's urban poorpopula tion. The leading causes of morbidity and mortality such as all forms of tuberculosis, bronchitis, pneumonia, measles, diarrhea and malaria are prevalent in urban poor communities.

Statistics show that the Philippine's urban poor population is estimated at greatest concentration in Metro Manila, where 3.5 million are spread out communities.

Of the 3.5 million, 1.9 are squatters living in areas such as shorel.ines and riverways. Such areas lack safe drinking water or ample water waste disposal system.

11 million with the in 415 urban poor esteros, sidewalks, supply for hygienic

Asicle from mlsau'dtary living conditions, poorly dis tributed and often subs tandard health services and facilities cause poor health among the urban poor. Likewise, the spiraling costs of hospitalization, medical consultation and medication prevent the poor from seeking health services.

Moreover, the poor's misguided health practices and their lack of knowledge and information on health promotion and disease-prevention contribute in worsenh'_g their health situation.

The state-run health care delivery network whlch provides primary to tertiary medical care is beset with budgetary constraints, thus the inadequacy in health care facilities and supplies to meet the majority's needs. An ordinary family person who gets a daily minimum wage of P127.84, more often than not, opts to lay ill in bed for days rather than spend around P82.50 for a simple medical consultation or a minimum of t:'96 a day and a night in a government hospital room or P396 in a private one.

On the other hm-Ld,theattitudes of most Filipinos towards healt_harecharacterized by: 1)a tendency to delay or i_*Lore preventive health care measures until illness becomes evident; and 2) a dependency OrLdoctors even for minor Complaints make the treatment of diseases more crisisoriented rather than preventive.

Both the government and the private sectors have done little to make quality health care more accessible to urban poor families. A lack of affordable health care financing schemes designed especially for the urban poor is prevalent.

The govenament's health h'tsurance program, Medicare, is enjoyed only by the company employees and those seK--employed who can afford to pay the monthIy premiums.

Despite the implementation of Phase II of Medicare which increases the benefits from 30% to 50% of medical expenses, low income families, especially those without regular paying jobs, still rely on their meager finar_cial resources to meet the exorbitant cost of hospital care.

Likewise, the prevailing private health insurance packages are not encouraging. These insurance |

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packages similarly require regular but higher premium payments which are affordable only to middle and higher income families.

-The gravity of the urban poor's plight in the area of health and the need to address it cam_ot be overemphasized.

It clearly demands for more genuine h-dtiatives and reforms on the part of both the government and the private sectors. It cannot be solved merely through improved technique.

Any lasting and effective solution must first deal with the cou.fitry's socioeconofn_c St_ctures which are at the root of most of the nation's ills.

The Department of Health's ODOH) present initiatives in clarifying its policy direction and formulating policies in health care Financing to accommodate special _;roup s such as the urban poor are a step towards implementing genuine reforms. It is hoped to open more avenues in providing quality health care to the poor.

Part of these initiatives of the DOH is the formulation of a research agealda for a health financing strategy. The conduct of baseline studies, including this particular study, aims to build a common base of information for health financing and health h_urance. With the baseline studies, the DOH hopes to set strategic options for adopting, formulating and implementing a more viable national health insurance system. The options will then guide the development of national consensus and action.

Given the DOH's goal of coming up with a more viable health insurance system for the poor, this study attempts to present a clearer picture of the socioeconomic situation of two urban poor communities in Metro Manila, nam.ely: Barangay Apelo Cruz LnPasay City and Barang.ay Bagbag in Novaliches. Likewise, this study discusses the two communities, perception arid attitudes toward health care and their willingness/readiness to participate in health care Financing schemes such as Medicare.

This study does not attempt to identify any viable health care fLnancingscheme for the urban poor because identifying such requires a separate study. However, while it concentrates mainly on providing baseline information as regards the two communities, it tries to present various factors that have to be considered in coming up with a mQre viable and substantial health care financing scheme.

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ii. STATEMENT

STATEMENT

OF THE PROBLEM

OF THE PROBLEM

G iven thus, this study attempts to answer the following: "What are the socioeconomic conditions in relation to health care of the urban poor Communities of Apelo Cruz, Pasay and Bagbag, Novaliches?"

STATEMENT OF THE OBJECTIVES Generally, this study wishes to ascertain the socioeconomic conditions in relation to health care of the urban poor communities of Apelo Cruz and Bagbag.

Specifically, this study aims to: 1. ascertain the demographic characteristics of Apelo Cruz and Bagbag; 2. determine

the perceptions mad _ittitudes of Apelo Cruz and Bagbag towards health care;

3. identify the health-seekhag behavior of Apelo Cruz and Bagbag; and 4. ascertain the wil!_n__ess and readiness o6 Apelo Cruz and Bagbag to participate in risksharh_g or cooperative prog maiatenance.

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III. STUDYFRAMEWORK

T

h_s study adapts the framework for the development of terms of reference for a study on health seeking patterns of special beneficiary group formulated by the DOH.-The framework identifies three key participants in the health care financing scherne, n_'nely: theb_eficiaries, the providers, and financial b_termediary or funders.

The framework states that the beneficiaries and the providers are directly lh_ked in self-financh_g sd_emes. The types of health care services rendered by providers are largely dependent on the capability of the beneficiaries in fia_ancing such services. Likewise, the types of health care services availed of by the beneficiaries are dependent on their capability to finance their health needs.

Financial intermediaries come into the picture to reconcile the inability of the beneficiaries to finance their health needs and the inability of the providers to shoulder the cost of the services needed by the former.

Tl'ds study agrees that the financial capability of the beneficiaries largely determines the type of health services they receive or patronize. However, it equally believes that the beneficiaries' sociocultural conditions m_d characteristics, their perceptions and attitudes towards health care, hffluence their health-seeking behavior and the type ofhealth services which they allow themselves to receive ea_d are willing to spend their resources on.

For instance, if the culture of the beneficiaries dictates that traditionalhealers or "herbolaryos" are more knowledgeable and credible as regards a person's health, then the former will prefer seeing these herbolaryos to medical professionals. On the otherhand, ifexperience tells these beneficiaries that medical professionals are more able to cure their diseases/_llnesses rather than the traditional healers, then they will seek the former's services rather than the latter's.

Likewise, accessibility to t_ealth care facilities and services provided by both goverrunent and private sectors influences the health-seekh}g behavior of the beneficiaries as well as their pattern of health care spending. For h_stance, if a private clinic is more accessible to the community rather thm'La health center, it is more likely that, even if it means higher costs, the commm_ity will go to private clinics rather than to centers.

Just as the socioeconomic conditions and characteristics influence the health-seeking behavior of the people in the commm_ity, so also the qualities and the capability of health care and the availability ofhealfll care resources determh_e the type and quality of health care services available to the people. For h_sta,'tce, a competent and poor people-oriented health service provider means quality health serviceat a cost affordable to the poor. In the same manner, adequate health care resources equal complete aJtd modem health facilities equal quahty health care services.

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Given thus, the study works under the following framework:

Fxcur E1

and Economic conditions '

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I -

PEOPLE

) [(BENEFICIARIES} -

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Availability of Providers 7 i

_,_]

Availability

HEALTH CARE _ -

SERVICES -

l,FinancialInt, ermediary I

[ ofre_ourccs

i

Aside from accepting the framework developed by the DOH, this study also borrows concepts from the framework of the participatory conscientizing research or better known as the participatory action research (PAR) wherein the participation of the people or the potential beneficiaries themselves in the conduct of the study is encouraged. Participatory research aims to stimulate the underprivileged in developing a more critical understanding of their reality and enhancing confidence in their abilities to solve their problems. The PAR approach enables the people/ beneficiaries to own the results of this study and decide amd take action based on the results. , Ideally, PAR should hwolve the.community in all phases - from the conceptualization of the research to the formulation of the research problems, objectives and design to the actual conduct of action based in the results of the study. However, more often than not, conditions in the field t'tinder the participation of the people in all the phases of the PAR. Thus, the people's participation is at dLfferent levels, dependh_g on the availability and capability of the community to participate in the project.

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DEFINITION

OF Tt_RMS

1. _g2_a_2r - refers to "squatters" with their makeshift dwellings crammed in almost every vacant lot in the city. Because they occupy land without the owner's expressed permission, one of the primary concerns of the urban poor is security of land tenure.

Comprised of casual laborers, various informal workers (i.e., peddlers, scavangers, drivers), unemployed individuals and employees with low wages. Urban poor's ia'_comeis marked by irregularities and nonpermanence and is way below the poverty line. The poverty threshold in Metro Manila is P5,921.

2. Health Care FinancingSdTeme G-tCFS)- refers to a system or arrangement wherein part or all of the medical expextses incurred by an individual or his/her dependents are paid by a third party.

The third party such as a health insurance receives regular payments or premiums from the individual specifically for this purpose.

A form of HCFS is the cooperative hx which members and their dependents become the beneficiaries while their organization stands as the third party to administer the collection and disbursement of the members' contributions.

Company-provided health benefits are either paid forby employees who pay a premium regularly, or part of the company's extende.d._.benefits to its employees.

Unless stated otherwise in the text, the term "Medicare" refers specifically to the SSS and GSIS Medicare.

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IV. METFIODOLOGY

T

_ descriptive study mainly utilized the participatory action research approach employing data collection techniques such as individual interviews, focus group discussions (FGD), and the community assemblies ......

ASSEMBLIES This study looked into three variables which were measured as follows: 1. Profi'le o/the two urban communities - refers to the demographic characteristics of Barangay Apelo Cruz in Pasay City and Barangay Bagbag in Novaliches. These include the sex, age, educational attainmea'tt, sources of income, and expenditures of the people in the communities.

Also included are the health care services and facilities and the organizations existing in the communities.

2. ttealth Attftudes, Perceptfons and Health-Seeking Behavior-refer to the people's perceptions and attitudes towards health care services, persormel and facilities in the communities and their health seeking behavior.

3. Health Care Ffnancing - refers to the various individual or group measures/actions the people to finance their health needs.

taken by

As mentioned earlier, the study e_.ployed the PAR approach. The participation of the communities concerned was encouraged and elicited in the formulation of the research design and of the instruments, h't cor_ducting individual interviews with household heads and ha facilitating focus group discussions with commmtity residents, analyzing the data gathered and in p.resenthlg the results to their respective communities for validation.

SELECTION OF RESEARCH POPULATION AND FORMULATION OF RESEARCH TEAMS The choice of the two urban poor commm't.ities for the researh population was based on the willingness of the community to participate, the availability of contacts h'_the community, and the level of community organization. The two commm_ities selected, after exploratory talks with each of the communities' formal leaders, were Barangay Apelo Cruz in Pasay City and Barangay Bagbag in Novaliches. Local residents of these two barangays were tapped and trai__edto conduct the study themselves with the assistance of the project facilitators.

Prior to the selection of the two urban poor communities, the research facilitators conducted social investigation.

The facilitators looked h'Lto the social, economic and political situations of the communities. They made courtesy calls on the formal and informal leaders, introduced themselves and the project they planned to conduct in their respective communities, and solicited the latter's approval and assistance, particularly h-tidentifying potential members of the two research teams, one for each barangay, to be formed.

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The selection of Research Team members was based on the following criteria:

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3.

4.

5:

a resident in the community, a respected person (of good moral character), can read and write well, has a pleasant personality, wi11K,'igt6-commit time and effort to the project.

The research team of Apelo Cruz was composed ofseven members. On the other hand, the research team of Bagbag was composed of eight members. Most of the selected members were the community leaders themselves. The members underwent a two-day seminar on PAR, its concepts and process (see Appendix A for the training module). The seminar was followed by a workshop whereby the participants were sent to the field to practise what they had learned in conducting a preliminary survey of their respective communities. Prior to the conduct of the preliminary su .ryey an interview schedule was formulated by the research teams themselves with the assistance of the project facilitators.

Every weekend, the research teams met with the project facilitators to process the former's experiences in the field. The weekend meetings were venues for the members of the research teams to report what they had done in the field, how they practised what they had learned from the seminar/workshop, the difficulties they encountered and the corresponding actions they took to overcome such difficulties.

Each research team conducted a brief political, economic, and social analysis of their respective communities. Likewise, the research teams conducted individual interviews (100 hi Apelo Cruz and 101 in Bagbag) and FGDs (three in each community with a total of 67 partkipants-33 in Apelo auLd34 in Bagbag) and facilitated a general assembly in each area with a total of 137 participants-67 h-_Apelo and 70 in Bagbag. In each activity, the research teams were accompanied by the project facilitators. In conducting the individual interviews, the research team members were divided into groups Of four-one h_terviewee for each group. accompm_ed the research teams.

For FGDs, at least two project facilitators

•SAMPLING OF RESPONDENTS The random technique was used inselecting the respondents for individual interviews. Household heads were assigned random numbers. However, as the research progressed a number of the selected household heads were unavailable for the interview. Thus, the research teams interviewed residents who were more accommodating and wi/ling to participate in the survey. A total of 100 residents from Apelo Cruz and 101 from Bagbag were taken as respondents.

On the other hand, purposive sampling was used for selecting participants in the FGDs. A total of 67 residents, 33 in Apelo Cruz and 34 hl Bagbag, participated in the six FGDs held.

RESEARCH INSTRUMENTS instruments used for the study were an interview schedule and an FGD guide (please see Appendices B and C for samples of the instnunents).

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The interview schedule in Filipino, formulated by the research teams with the assistance of the research facilitators, adopted some of the question items in a survey questionnaire designed by government institution spearheading the research studies. The research teams conducted a pretest after the formulation of the instrument. During the pretest, it was learned that the instrument was too long for the respondents that the latter refused to finish the interview anymore. Thus, necessary changes were made to shorten the instrument.

The final instrument included sections related to demography, income and expenditure. It also included questions regarding health attitudes and perceptions and health-seeking behavior, and their willingness and actual capacity to participate in risk sharing schemes.

Aside from the interview schedule, an FGD guide was formulated by the research facilitators in consultation with the research teams. The guide included items on the people's knowledge, awareness, and experience on health care t"manciag schemes such as Medicare and their willingness to participate in the formulation of a scheme that is more viable and sustainable for them.

DATA GATHERING Data gatherh_g phase of this project (FGD, survey, general assembly) lasted _Qte (9) months from May 1992 to January 1993. The research teams accompanied by the project facilitators went from house to house and interviewed the household heads identified as respondents. Each interview took an average of two and a half hours.

Aside from h_dividual interviews, the research teams conducted focus group discussions participated in by 10-15 household heads (either father, mother or both). Durh'tg the FGD, the participants were asked to role-play their attitudes and perceptions on health.

In the process of conducting individual interviews and FGDs, it was learned that most of the respondents were m_clear about Medicare and largely ignorant about health mainten'ance organizations and health h'_surances. Thus, the project facilitators with the assistance of the research teams held education sessions and distributed pamphlets in Filipino on the said concepts.

Data ga[lterh_g was temporarily disrupted for about three to four months because of the 1992 synchronized national arid local electiorts. The communities were highly involved in the election proceedh_gs. Mith_g de ava.nce in the communities and other campaign activities delayed the training and post training self-assessment of the research teams.

In Bagbag, an httense in-fighting occurred among the leaders because there were factions which supported various condidates. of a particular car_didate.

The research project was even branded as an extension program

DATA ANALYSIS For qualitative data, descriptive analysis was used. On the other hand, for quantitative data, descriptive statistics such as frequency distribution and simple percentage and indices of central tendency such as the mean, median m_d mode were employed. A "p" values less than 0.05 was considered signidicant.

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DATA

VALIDATION

The results were presented in two separatebig group assemblies, one in each ¢ommunlty studied.

In the assemblies tlte people gave their feedback, validated the results and provided recommendations and additional information pertinent to the study.

FEEDBACK ON THE RESULTS OF THE RESEARCH

In Pasay, 67people attended the assembly conducted in front of the day care center along the main street of the community. The barangay officials mad the executive dkector of Ina-Anak, one of the NGOs working in the community also attended.

The participants co_ffirmed the results of the study. Their reactions toward the establishment of an HCFS ha their community were generally positive. While validating the results of the study, they expressed strong reactions toward the quality of health services provided by the health center.

They gave suggestions to improve the center's services. These included making essential drugs available; longer clinic hours; and hiring more competent and caring personnel.

On theissue of health care financing, those present were amenable to an HCFS whose structure and guidelines were acceptable to them. Moreover, they suggested that a strong community organization handle the HCFS to safeguard the funds.

However, no concensus was reached regardh'lg the premium to be paid by meml_ers. Some were willia_g to corttribute as much as P100 a month. Others could only afford P5 a month.

Nova fiches

i

In Novaliches, a total of 70 individuals participated in the assembly held ha an open basketball court. Among those who attended were officers of the different community associations and people's organization.

Like ha Pasay, the participants expressed their approval as regards the results of the study.

The ensuing discussion centered on what services the health care financing scheme should offer.

Many felt that the emphasis should be on outpatient care more than on hospitalizations. Mothers, ha particular, were more interested in making health care services available to the children. Again, no consensus was read'ted on the premiums to be paid. The group suggested a thorough study on the matter of premiums.

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V.

FINDINGS

AND DISCUSSION

Discussion of the

findings of the study is divided into four parts. The first part presents the demographic characteristics of the two urban communities, Apelo Cruz and Bagbag. The second part deals with the communities' percep tions and attitudes toward health care and health-seeking behavior. The third part discusses the communities' perception and attitude toward and willh_ghess to participate in risk-sharing on health care maintenance. Lastly, the fourth part discusses the implications of the findings in the formation of health care financing ha the two urban poor communities. It discusses the factors which may facilitate and hinder the successful implementation of whatever financing scheme would be formulated.

A. PROFILES OF THE COMMUNITIES 1. Baran__ay Ap¢lo Cruz, pasay TI_¢.Place and the People Barangay Apelo Cruzis situated along the Tripa de Gallena creek. Owned by the Alcantara family, its total land area is approximately 40,000 square meters. It has a total population of 4,500 with 1,500 total number of households as of the 1986 local survey. Presently, residents estimate their population as at least twice that number.

Art average of three families live h_i..acramped house, usuaUy,a two-story type, of scraps of wood and iron sheets along the polluted river which smells of filth. The houses are built close to one another makhtg ventilation very poor.

Most of the residents who used to be farmers came from the Visayas, Ilocos and 13icolregions.

People have been migrating to the area since the 1950's. Most of the people engage in scavenging.

Some are employed as side-car drivers, construction workers, factory workers, mechanics, security guards and janitors.

NGOs and POs present in the area h_clude Apelo Women's Health, Samahan ng Nagkakaisang Magulang sa Apelo, SAMAKANA, KABAYAN, ERDA, Apelo Youth Association, Apelo Youtl_ Servant, SAMANA, Lumipas na Kahapon, Rotary Club, Kabataang Barangay, and INA-ANAK. Apelo Cruz has two govenxrnent health centers, a general hospital, 13 private clinics, a day care health cea'tterand a women's health center. Common diseases in the area are cough and colds, fever flu and diarrhea.

The Resvondents A total of 100 residents were taken as respondents participated in the three FGDs conducted in the area.

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EducationaiAttainment

Akrtost all (87) of the total respondents were females (please see Table A1). They had lived in the area for more than three year5 already. Their stay in the place had been largely dependent on the avaHabi.lity of work and security of land tenure. Almost haK of the respondents (41) were young, between 21 and 30 years old (see Table A2). Of the total number of respondents, 67 were able to reach high school_Of the 67, 41 were able to finish high school(please see Table A3).

TABLE AI. SEX SEX

TABLÂŁ A2, ACE RESP.

1. Female 2. Male Total

87 13 I00

AGE (Years) 1.

2.

3.

4.

5.

6.

RESP.

_t7-20 21-7,0 31-40 41-50 51-60 61up

9 41 27 10 12 1

_'otal

TABLEA3. EDUCATIONALATTAINMENT

['ABLEA4. I"_OUSEHOLD MEMBERS

LEVEL

qO.OF HH MEMBERS

1.

2.

3.

4, 5, 6.

EIement.ary Elementary graduate High School High School graduate College ColIegegraduate

Total

Ho_tsehold

I00

lVfe+nbers, bjcome

RESP. 9 16 26 41 5 3 1(30

RESP.

1, 1 2. 2 3. 3 4, 4 5. 5 S. 6 7. 7 8. 8 9.9 10. 10

0 2 18 23 16 18 12 6 5 0

Total

1(30

and Expenditures

Most of the respondents (23) had art average of fourmembers per household. Majority earned from P3,000 to P4,000 a month as scaveaagers, factory or construction workers (see Table AS). The average montt'dy expea_ditures of a family of four or five was P4,517 (see Table A6).

The bulk of their expenses went to food and groceries (P2,957.48 or 65%), followed by expenses ha vices such as smoking and gambling in the form ofjueteng, bingo, sakla, horse racing, and endhag ....

i

i.

.

...

i

15

(P420.80or 9.29%). Very minimal (P81.08or 1.79%)went tohealthneeds and education (P76.62or _1.68%). However, a considerable amount went to transportationand clothing(P359.39or 7.9%), utilities such as payment for house rent and electTidty(P$12.40or 6.9°/o), and others such as appliances bought on creditor "'hulugan" or sma11-scalebusinesses such as Hvestock raising (P271.80or 5.99%).

TABLEAS. AVERACEMONrbILYINCOMEPER HOUSEHOLD INCOME I. 2.

3.

4.

5.

6.

RESPONDENTS

PI,000& less PI,001-1,999 P2,000-2,999 P3,000-3,999 P4,000-4,999 P5,000-up

11 8 15 32 34 0

Total

100

TABLE A6. AVERACE EXPENDrrUREPER ITEM PER MONTH ITEM 1.

2.

3.

4.

5.

6.

7.

8.

AMOUNT (P)

Food & Groceries Transportation & Clothing Vices Utilities Entertainment Health Education Others

Total

Organlzhtions

Involved

hi and Benefits

o/_

2,957.48 359.39 420.80 312.40 37.52 81.08 76.62 271.80

65.0 7.9 9.29 6.9 0.8 1.79 1.68 5.99

4,517.09

99.35

Received

Majority (78) of the total number of respondents were members of a community organization.

The rest were members of a church-based organization or an organization wt_ch an NGO helped established.

The benefits they received were usually in the form of loans. Some also received doleout assistance in cash or in kind.

L i

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...............

TABLE A7. ORGANIZATIONS INVOLVEDIN ORGANIZATION 1.

Church-based

2.

3.

Community Non-govemmenl_l

RESPONDENTS 4 78 8

4. Others

2

Tohal

92

TABLE A8. ASSISTANCE._F.C,Y.IVED [FROMORGANIZATION ASSISTAN

1.

2.

3.

RESPON DENTS

CE

Cash (dole-out) Loans In kind

25 60 12

Total

2.

Barang_y

97

Bagba_Novaliches

The Place and the People Barangay Bagbag is siVaated in Novaliches. area of 245 hectares. It has a total population living as factory and construction workers,

It is composed of six sitios and occupies a total land of 18,700 with 3,800 households. The people earn their vendors, overseas and agricultural workers.

The commmxity has three private clinics, a private hospital, puericulture center and lying-in clinic.

No health cea'tter exists in the community.

Thepe9ple have yet to go to Tandang Sora, a 15-minute walk from the place, to consult at the health center. Common diseases h-t the area are cough and colds, fever, flu and diarrhea.

77_e Respondents A total of 101 residea'Lts were taken as respondents participated in the three FGDs held in the area.

Sex. Age andEducationat

for the individual

interviews

while 34

Attainment

Majority (90) of the respondents in the individual interviews were females (see Table B1 below).

Majority of them were between 21 and 30 years old (see Table B2 below). A-round half (49) were high school graduates.

However, a considerable number, (28) were elementary graduates (see Table B3). i

ii

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,

TABLE B1. SEX

..

• .

:

TABLE B2. ACE

'SEX

RESP.

I. Female 2. Male

ACE (Years)

90 11

Total

101 --

I. 17-20 2. 21-30 3. 31-40 4. 41-50 S. 51-606. 61up

RF.SP. 3 35 29 22 7 5

--

Total

101

TABLE B3.EDUCATIONALATIAINME.NT

TABLE B4.HOUSEHOLD MEMBERS

LEVEL

NO. OF HH MEMBERS

1.

2.

3.

4.

5.

6.

RESP.

Elementary Elementary graduate High School High School graduate College College graduate

Total

3 28 7 49 8 5 101

Household MembersLIncome

RESP.

1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 B. 8 9.9 10. 10

S 4 14 29 19 10 10 4 3 3

Total

101 "

a_fl.Exp,enditures

The average nLunber of household members of the respondents was four (see Table B4). Monthly income of fl'_erespondents rmlged from P2,000 to P4,000 (see Table B5). The average monthly expenditure per household was P4,103 with the bulk going to food and groceries (P2,698 or 65%).

A considerable amount (P456 or 11%) went to transportation and clothh_g. Least amount (P37 or 0.9%) went to education. A mhdmal amoua_t (P126 or 3%) was also spent for health needs. Other expenditures were on vices which included smoking and gambling (P266 or 6%), entertahtment which included seeing movies (P103 or 2%), and uti]ities which h_cluded payment for house rent, house repairs, and electricity (P296 or 7%).

TABLE BS. MONTHLY INCOME PEa HOuSEHoLD INCOME 1.

2.

3.

4.

5.

6.

P1,000 Pl,001 P2,000 P3,000 P4,000 P5,000

Total

......

- ....

RESPONDENTS & less - 1,999 -2,999 - 3,999 - 4,999 - up

10 13 27 25 26 0 I01

u

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TABLE•B6. AVERAGEEXPENDITURE PER ][TF.M

ITEM

AMOUNT(P)

%

I. Food & Groceries 2, Transportation & Clothing 3. Vices 4[-"Utilfffes S. Entertainrnent 6. Health 7. Education 8. Others

2,698.16 456.28 266.40 296.59 103.40 126.80 37.16 118.40

65,75 11.11 6.48 7,21 2.51 3.07 0.9 2,87

Total

4,103.19

99.90

_Orcanfzat_'ons Invo Ived In Of the total number of respondents, 60 were members of organizations existing in their place.

Almost half (27) were members of a community organization. The rest were either members of a church-affiliated organizatior_ or ar_organization established by an NGO. Assistance rendered to the members of the organizations mentioned were usually in the form of loans, and dole-outs h_ cash or in kind.

A com.m_xity organization in the community which had more following than the other existing organizations in Bagbag was the Nagkakaisang Samahan ng Maralita (NAKASAMA) whose primary aim was to ensure their members' continued stay in the community. In NAKASAMA, members paid monthly dues of P5 for the association's upkeep. Another form of payment was "suyuan" or "bayanihan" wherein the members rendered labor services instead of money.

TABLE B7. ORGANIZATIONSINVOLVEDIN ORGANIZATION 1. .Church-based • 2. Community 3. Non-governmental 4. Others Total

RESPONDENTS 13 27 19 1 60

TABLEB8.ASSISTANCERECEIVED FROM ORGANIZATION

ASSISTANCE 1.

2.

3.

Total

Cash (dole-out) Loans In kind

RESPONDENTS 17 18 28 63

,

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19 l_

Unlike the preceding section which separately discussed the demography of the respondents from Apelo Cruz and Bagbag,thesucceedingtwo sec_onsjoLntly discuss [heattitudes, perceptions and healS-seekingbehaviorand risk-sharing on healthfinancing oftherespondentsgiventheir similar patten_ (pleaseseetablesA9 and AI2 and B9 and BI2 on respective healthattitudes, perceptions m'Ldpractices oftherespondentsforcomparisonpurposes).Responsesdiscussed inthesesections were culledfrom theindividual interviewsand theFGDs.

B. HEALTH ATTITUDES, PERCEPTIONS AND HEALTH-SEEKING BEHAVIOR Concept

of FIealth

While most oftherespondentsagreedthata healthypersonisa personwho hasnotbeensickfor a long timeand thatboth therichand thepoor have thesame healthproblems,theydidnot see theneed toregularlyseea doctorformedicalcheck-up.They would seea doctoronlywhen ill More oftenthannot,itisthechildren whom theywould bringtothedoctors forconsultation.

Given theirweak and frail bodies,thechildrenaremore susceptible todiseases.

A mother onceshared thatselfmedicationwas enough forolderpeoplelikeher.

Health

Workers

The respondents expressed strong faith in medical science, agreeing that a doctor knowledgable on health matters than the traditional healers or "herbolaryo",

is more

Professing confidence h't the ka_owledge and expertise of medical doctors, most of the respondents usually consulted a doctor at the first sign of ilktess. However, some resorted to self- medication rather thml consulting a health professional.

Others consulted a midwife or an herbolaryo.

Still others sought friends or relatives for advice.

Herbolaryos were usually consulted a 54-year old man who wa s suffering no cure was possible for the former's case was that of a 32- year old woman an herbolaryo because she could not Health

Services

during seemingly hopeless cases. A case in point was that of from tuberculosis.

The patient and his family thought that illness anymore. An herbolaryo was the last resort. Another who.was also suffering from tuberculosis.

She went to see afford a medical professional's consultation fee.

in the Commltnit!t

Most of the respondents described the available health services in their communities as inadequa re.

In Pasay, the doctor in tile health center was available only on Saturdays. On the other hand, in Bagbag, the nearest health center was a 15-minute walk from the community.

Moreover, more often than not, medicine in these health centers were not available. And if they were available, these medicines were sold instead of given free as had always been expected in public health centers.

A mother shared that she once brought her child suffering from tuberculosis to a health center. She was given free medicines.

However, when she and her child arrived home, she learned that the

, _

2O _--

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•

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medicines werepasttheir expiration date.Shedidnotlet herchild takethemedication anymore for fear that the hatter's illness would worsen.

II_e of _he Health Servfces (Gove_rn.mentvs. Private) More often than not, respondents sought private health services rather than government ones.

Even if seeking private health services meant higher expenses, the respondents preferred the former to the latter because they perceived the former as of better quality.

The respodents provided a distinction between a government doctor and a private one. For them, private doctors were more competent. They preferred private doctors to government ones because aside from being more competent, private doctors were more available and their clinics were more accessible aa_d they had medicines. Moreover, private clinics or hospitals had adequate facilities.

They would only see govenunent doctors and confine themselves in government hospitals as a last resort. Either they did not have any money to seek private health services or they needed immedia te relief from their illness and the nearest clinic or hospitalwhere they could get such relief was a govenasrtent one.

Apelo Cruz's residents lamented that the doctor in the barangay health center was available on Saturdays only. Moreover, the health worker tasked to administer first aid and take a patient's blood pressure gave priority to patients known to him personally. More often, only those he knew received treatment.

In addition, medicines such as analgesics and antibiotics, when available, were sold instead of given free. The respondents expressed their willingness to pay as much as 50% of the cost of medicines provided they were of good quality. i

Meanwhile h'tBagbag, residents consulted cough and colds only. They would rather cough with fever. Even if it meant higher • the private practitioners because the cost

the nearest health center for very minor complaints like see private doctors for more serious problems such as cost, around P200 per consultation, they would still see already included the medicines.

In Apelo Cruz, when the respondents were suffering from cough, abdominal pains or sirr{ilar complaints that they needed immediate relief, they consulted at the nearest hospital which was a government one.

Relatives of a 54-year old woman confined at a private hospital run by a religious congregation were very satisfied with the service rendered during the latter's co_ffinement. The same however, could •not be said about their experience in a government hospital where they were forced to transfer the patient when they ran out of fuatds. The relatives described the said government hospital as dirty and complained about the lack of doctors on call.

21 •

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D!ntgs and Prescription Irrational drug use abound with the rampant use of ant4biotics even for clearly viral infections only such asfluwhere antibiotics areura_ecessary.

They oftenequatedillness withmedicines.

For perceivedvery minor complaintslikecolds,tlley attemptedself-medication.

However, for most oftheirotherbodilyComplaints,theyrelied heavilyon doctors.

More oftenthannot,respondentsdid notcompletea prescribed drug regimen iftheyfeltsome relief from their ailments. Leftover medicines were saved for a recurrence of the same symptoms.

On the other hand, they would stop taking their medicine if they perceived that such a medich_e was ineffective.

A case in point was that of a 32-year medicines when she felt that they had institute for tuberculous patients in the additional medicines.

She consulted a money ran out.

TABLE A9.

old womanwith tuberculosis who stopped taking her not been effective. She had already been admitted at an past. However, she had not returned for a foLlow-up or for few private practitioners who gave her injections until her

INDIVIDUALS USUALLYCONSULTED DURING ILLNF_S IN APELO

PERSONNEL 1. Doctor 2. Nurse • 3. Midwife" 4. Herbolaryo 5. BHW (Brgy. Health Worker) 6. Relatives & Friends 7. Others

RESPONDENTS 34 0 3 3 0 18 10

Total

TABLE B9.

68

INDIVIDUALS USUALLY CONSULTED DURING ILLNESS IN BAGBAG

PERSONNEL

RESPONDENTS

1.

Doctor

2.

3, 4.

5.

6.

7,

Nurse Midwife Herbolaryo BHW (Brgy. Health Worker) Relatives & Friends Others

0 3 4 4 4 7

Total

.

_

•

33

55

....

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22

TABLZ AI0. A't-rlrUD_, PERCEP'rIONS, P_cTlc,t_S o_ At_EkoCKuz A. ATHTUDES,

.....

PERCEPTIONS, PRACIqCES

RESPONDENTS YES NO

I. Beinghealthy isnotbeLn S sickforalongtime 2. Only ill personsconsult doctors 3. _Therichand_poorhave thesame health problems B.

HEALTH WORKERS

30 32 28

Y_

1. The"herbolaryo" isahvays correct 2. The doctorisalwayscorrect C.

69 67 71

NO

20 83

HEALTH SERVICES IN THE COMMUNITY

76 16

YES

1. The health servicesare adequate 2. Government doctors are as good as priva'te ones 3. Private doctor_ treat therichand poorequally D.

USE OF HEALTH SERVICES

1,

Between a government and a private hospital, I'd prefer a private one if costs are the same

NO

37 65 22

34 78

YES

NO

65

35

2, Iwould prefer a private hospital toa government one evenifthelatter offers excellent service and it is cheaper

78

20

3, Very sickor dyingpersonshouldbebroughttoa government rather thhn a private hospital

91

6

4, Sickelderly persons shouldbebroughttoa government rather than a private hospital

85

' 8

Iam interested in joining a health care financing scheme

92

6

I am willing to give regular dues (either monthly or weekly) in the financing scheme

94

4

YES

NO

83

15

49

48

5,

6,

E.

DRUGS AND PRESCRIPTION

1.

A good doctorshouldprescribe a medicine tO sickpatient's

2, A patient who feels better canstoptaking. his/her medicine even if the regimen prescribed has not beencompleted 3, One can takepreviously prescribed medicineforan illness which seems

4,

..............

.

similar tO the previous one.

49

49

One should take antibiotic right away if one is sick

49

49

m

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23 .....

.

TABLE

A.

"_10.

A'rTI'I'UDF.St

....

: i

-

_RCEI'TIONS

i|

x _RACTICF.$

•

ATTITUDES, PERCEPTIONS, PRACTICES

HEALTH

59 66 50

WORKERS

NO

28 ' 74

HEALTH SERVICES 1N THE COMMUNITY

72 27

YES

USE OF HEALTH SERVICES

NO

47 56 48

57 45 55

YES

NO

I. Betweena government and a privatehospiml, I'dprefer a private one ifcosts arethesame

64

37

2. Iwould prefer a private hospital toa governmentone evenif thelatter offers excellent service and it is cheaper

72

28

3. Verysickordyingpersonsshouldbebroughttoa government rather than a private hospital

77

24

4. Sickelderly personsshouldbebroughttoa government rather than a private hospital

78

, 22

[ ant interested in joining a health care financing scheme

92

9

I am willing to give regular dues (either monthly or weekly) in the financing scheme

92

9

YES

NO

63

18

34

67

37

64

27

74

5,

6.

E.

DRUGS AND PRESCRIPTION

I. A good doctorshouldprescibe a medicine to sickpatients 2.

A patient who feels better canstoptaking his/her medicine even if the regimen prescribed hasnot been completed

3. One cantakepreviously prescribed medicinefor an illness which seems similar to the previous one.

4.

, .

41 35 50

YES

I. The healthservices areadequate 2. Government doctors areasgood aspdvateones 3. Private doctors treat the rich and poor equally D.

•

RESPONDENTS yES NO

I. The "herbolaryo" isalwayscorrect 2. The doctorisalwayscorrect C.

i

OF "_AO_AC

I. Beinghealthy isnotbeingsickforalongtime 2. Only ill personsconsult doctors 3. The richand poorhave thesame health problems B.

i

One should take antibiotic right away if one is sick.

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C. HEALTH CARE FINANCING Sources of Funds for Medical Needs Sources of funds identified by the respondents inboth individual interviews and FGDs for health care needs such as consultation, medicines and hospitalization included: own earnings, donations or loans from friends or rela rives, loans from employers andusuxers, other sourcesofincomesuc h as scavenging or buying and s_lliug scrap material for recycling, Medicare/health insurance, selling or pawning of properties, "paluwagan", company-provided benefits, and service-oriented government or nongovernmental organizations.

DonatirmsfromRelatives. The relatives reterred towereparents, grandparents, siblings, uncles and aunts.

Any financial assistance received from relatives, no matter how small,was usually the most substantial because no payment was expected.

Loans_om ernplcaders.

Loans fromemployerswerehsua]lyintheformof._.alary were made through salary deductions over a certain period of time.

advance. Loanpayments

Loans from usurers, h't the communities, several known usurers would lend money with 20% interest usually payable in one month. Much as they resented borrowing at usurious rates, the people were forced to because it was the easiest way of securing loans- no collateralrequired and always available during emergencies.

LoaT_sfrom_ie_[dsor relatives. Unlike loans from usurers, loans from friends or relatives were without any interest. However, such Ioanswere expected to be repaid within a certain period of time agreed upon by both borrower and lender.- " Medfcare/lnsurance. Respondents who had regular paying jobs in the goven_ner_t and private sectors have Medicare benefits provided by GSIS or SSS. The GSIS or SS$Medicare shouldered some of the hospitalization expenses of the respondents. However, some respondents expressed dis_stisfaction with some Medicare pohcies. They explained that the Medicare was applicable to hospitalization only and not to outpatient services. Since they seldom got hospitalized, they had not been able to use their Medicare sh'tce they started giving contributions.

Likewise, sluce some members had not been properly oriented about Medicare, they had not been able to avail of its benefits. Nevertheless, despite the perceived lopsided policies of Medicare, the respondents Still saw the value of mah-ttaning their Medicare, especially for hospitalization purposes.

They recommended tl_t Medicare increase its benefits which would also cover outpatient services a_d concerned authorities should make the processing of the papers easier. ,qaleofproper_t_.Some responde_nts resorted to selling some of their valuableproperties to cover medical expenses. A family was forced to sell their house at a very low price and hved with some relatives.

Another sold their pig which they were supposed to raise as additional source of income. paz_mi_gofbelon_t_s. Pawnshops aboundnear these 2urbanpoor ct_rnmtu-tities.However, very few valuables of tlle urban poor cm]be pawned. Nevertheless, some of the respondents pawned some of their properties eaxd redeemed them once they had been able to secure the money.

• i

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25

=,,

i

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Some of the community members banded together and regularly contributed a certain amount to a hand. The members tool_ff-ui'nsin withdrawing the fund atspecific periods of time. During emergency cases, one could arrange to withdraw the fund ahead of schedule.

Company provided benefits.. Some companies wi.'thwhich some of the respondents worked provided health financing schemes for their employe4sl .Theseschemes Tequired c_o_mpulsorycontributions from the employees. The schemes partially coVered expenses for hospitalization, doctors' bills, dentalservices, maternity, and medicines.

In one case, an employee who had an I_MO did not spend anything for his hospitalization.

Nevertheless, he lamented that the accredited hospitals Were far from his residence. Likewise, out-patient consultations were on a refund.basis and claiming his refund entailed excessive paperwork.

An employee of a hospital in Manila, in addiiio'_-f6_..l_"Medicare benefits, had most of his hospital bills settled through salary deduction. Furthermore, his doctors waived their professional fee and offered to do the same for his dependents. .

GovernmerLtavencies, private organizations, philantropists or politicians. Since government hospitals could only do so mud'_ h-tproviding discounts to the indigent upon discharge, the respondents tapped all available groups or persons who were willing to render assistance for their medical needs. Some organizations, like the Women's Auxiliary Group, provided substantial help in the form of medicines.

In Apelo Cruz, a health cooperative.was established by Gabriela, a network Ofwomen organization. The cooperative provided services such as loan assistance, freemedical consultation, discount of as much as 50% for the total cost of medicines, and free herbal remedies. A nomhnal fee or voluntary labor services served as contributions or capital share of the members. ' Other sources qf income. Some people were able to get additional work such as part-time construction workers to eant a little more money. Others sold scavenged scrap metal and other items for recyclh'tg.

T,_sL_ All. Sousc_s oFFUNOS Fo_CONSU=-TATIONS OFAr_tOCRuz SOURCE 1.

2.

3.

4.

5.

6.

7.

RESPONDENTS

Own pocket/savings Salaryadvances Insurance Loans Saleofproperty ' Pawnofproperty O_ers

26 2 0 1 0 16 2

To_al

47

• •

.....

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TABLEA12. Sou,Lc_ o_FuNDsFoR HOSPrrAL_'_fl OF APELO CgUZ SOURCE I. 2.

3.

4.

S, 6.

7.

.... .7.

RESPONDENTS

Own pocket/savlngs Salaryadvance .: Insurance Loans $ale of property Pawn of property " Others

Total

29 0 3 16 3 2 1

" '"'

54

TABLEBll. SOURCESOFFUND$FORCONSULTATION OFBAGBAG SOURCE

RESPONDENTS z.

I. 2.

3.

4.

5, 6.

7.

44 4 0 ] 0 0 3

Total

,

47

TABLEB12.

SOURCESOFFUNDSFOR }-_OSPITALIZATION

OF ]_AGBAG

SOU RCE 1.

2.

3.

4, 5.

6.

7.

RESPONDENTS

Own pocket/savings Salary advance Insurance Loans ' Saleofproperty . , Pawn of property , [i Others

Total

Participation

.

Ownpocket/s_ .... 6=.,.

Salary advance Insurance , Loans Sale of property Pawnor property ,• Others

9 0 0 2 2 1 3

'

17 •

in Risk-Sharing

Seeing the value of saving money for emergency situations such as for medical expenses, most of the respondents expressed their willingness to participate in a Health Care Fham_ch_gf :heine m ...

_ ........

•

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27

(HCFS) that would be suited to their needs and Capabilities. They were willing to pay the required or agreed upon premiun provided the polides:were according-to their own terms - that the insurance would cover accidents, calamities, and overall health maintenance, and, i/possible, the college education of their children. The following were the other terms they wanted implemented in the planned HCFS: 1.

2.

3.

4.

• A well-orgamzed peop 1e' s organizationbased in the community should manage the HCFS. A very good system of recording should be maintained.

A fiaxancial report should be provided to the members re_/arly.

The monthly share should not be less fl'u_'p5 and not more that 1>30.A P20/month share is reasonable.

5. 50% of the total share of the member per year should be refundable if benefits were not availed of.

Recognizing that they might have somepromems as regards faithhzlly paying the premium for the HC FS given their meager income, the respondefits cited tapping donations from both government and private institutions, remittances of relatives working abroad, and expected profits from their small businesses as other possible sources offunds. Some even expressed willingness to cut down on their vices such as smoking and gambling tOhave money to pay for the premium.

D. FACTORS THAT MAY FACILITATE OR HINDER THE IMPLEMENTATION OF AN HCFS The followh'lg section discusses thepossible factors which may facilitate or hinder the successful implementation of an HCFS in the b,vo urbanpoor communities based on the f-mdings of the study.

The factors include values, attitudes and existing structures in the communities.

Factors That May Facilitate the Formation of a Successful Health Care Financing Scheme TI_e"'Pahtwa_an ":System The people's favorable attitude towards "paluwagan" which requires an agreed upon regular contribution from those involved is a distinct advantage when setting up a financing scheme. This shows the people's wi.Ilh_gness and determination to set aside a part of their ean@_gs and give as contribution to something which fl_eybelieve would benefit them. To illustrate, the "paluwagan'" had been a source of funds to finance hospitalization expenses.

The Amor Propio or Word of Honor The people renders high value in meeting financial obligations. Failing to meet obligations, particularly financial, means a loss of face or Credibility among community members. Because urban poor communities are usually small, congested places where residents know one another quite well, the community would know who kept and did not keep his/her word. i .....

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Positive Attitude_ Toioard_ HeaIth. Medical Doctors an;l UtiIization of Medi¢_ties Respondents value their health greatly. They, especially the mothers, see it as a priority concern.

Moreover, they have high respect for doctors, particularly the private practitioners. They consult doctors, go to health centers, private clinics or hospitals_to so_okmedical services even if it meant shelling a portion of their meager _come.

Established medical practitioners and existing health facilities in the communities, whether government or private, may be included in the scheme in trying to lower the capital outlay for the health system. It is just a matter of striking abalancebetween the need of the doctors to earn a livhag and the financial capability of the people to meet their health care needs.

Willin_jess

to Work for

Services Receive#

.......

Always short of cash, the urban poor are more than willing to render labor as payment for services they receive. Perhaps, they could be employed (o maintain and improve existing health centers in order to reduce operating costs.

Positive Attihtde

Towards HCFS or Medicare

Despite perceived loopholes in the Medicare programs of GSIS and SSS, the people still see it as necessary h_ meeting their health care needs, especially during hospitalization. They expressed interest and willingness to participate in a health care fir_ancing scheme or HCFS whose terms would be acceptable to them.

The Ex'tended Family The extended family is a strong and helphal institution which can be tapped in sus raining regular contributions to the HCFS. It is customary among Filipinos, especially among the poor, to accommodate extended family members to .their homes. These family members have always helped one another, especially in times of need, without counting the cost. As illustrated earlier, household heads Usually turned to parents and other relatives for assistance to shoulder medical expenses.

Existin_ Orsanizations

in the Comrnuniti¢_

The orgmxizations, whether NGOs or POs, in these communities are firmly established and have already gained the respect and co_ffidence of the people. Their years of existence h_ the communities have earned for them considerable experience in dealing with the people.

Lh'tkhlg or networking with these orga_xizations could facilitate the establishment, implementation and rnonitorhlg of an HCFS in the community since these organizations have already insti_ltionalized the necessary systems _t the effective and efficient irnplementatior_ and mor&orh_g of programs/projects with the people. Likewise, NGOs could also be tapped in providing teclulical assistance to local residents, particularly in managing an organization or an HCF$. n

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Factors Thay May Hinder The Formation .

Of A Successful Health Care Financing Scheme Crisis-Orientation

Towards

HeaLth

The urban poor's crisis-oriea'ltation towards heai_ may pose a hindrance. The people have been used to having other people providing emergency assistance to them, espedally during-times of crisis. Changing the status quo may meet some resistance from the people. It wilt take timebefore a change in orientation could occur.

Nffsconceptions

Abou_ Ratfon.al

Health

Care.

Setting up a health care fmanch'tg scheme that p.,.,_omaLl.,hasison rational and preventive health care may encounter some difficulties given the curative rather than the preventive health concept of the people. Therefore, an educational campaign is necessary to ensure the success of the scheme.

Lack of Confidence

in Government

Health Facilities •and Personnel

The lack of cotffidence of the people in government health personnel and facilities and their exasperation over govenm_ent bureaucracymaybe detrimentalto the implementation of a scheme which would elicit the support of the government.

It is therefore necessary to convince the people of.the sincerity and commitment of the government to provide adequate health carefor all. It is equally necessary toimprove the image of government health persormel and upgrade government health facilities, particularly the health centers.

Idea logica I Lean ings of Existing

Organizations

in the Community

Some orgalzizations in the commmxities have varying ideological leanhlgs which may cause conflicts witl'_ other organizations.

Tl_e"group'" mentali W of theurban poor may hh'_der the setting up of an orgmzizationaI backbone to the scheme.

Lack of Technlcal

Skills

and Cap_bitity

Most of the residents of these urban poor communities are unskilled workers who have reached high school only. Thus, they lack managerial and administrative skills to run a successful ea_terprise on their own. Trah_ing of potentialleaders and members is therefore necessary prior to the implementation of an HCFS. Lack of R¢_dar

Source of Income

The people barely manage to make both ends meet. Therefore, much as they expressed their interest and willh_less to participate in an HCFS, paying premium is an added burden for them.

Some mechanisms should be sought and put in place to ea_courage and help them to participate in the scheme.

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Poor Livln_ The poor living condition of the people is often the cause of diseases among the people. In a health plan, more people becomh_g sick means more expenses. And more expenses mean higher premium payments. Educadonalcampaignsandprojects toimprove t.helivmgconditions are thus necessary to prevent the outbreak of corrun_nicable diseases caused by unsanitary living conditions.

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31 i

Wl. SUMMARY

AND CONCLUSION

SUMMARY

Household headsofthetwo urbanpoorco'unitiesstudied wererelatively young-between theages21and 30.Most ofthemhad readied orfinished highschool.

Theyhavebeeninthearea formore than3 yearsand had no defmlte p_s ofmigratlng toanother place, Most ofthemcame from the provinces. ::. -::--:_..

The families earned their livikng as scavengers, construction and factory workers, janitors, security guards, and by doing the laundry of other people. With an average family of four, the average monthly income was slightly in excess of P4,000. The bulk of their monthly expenditures, averaging P4,500 monthly, went to food andgroceries while a considerable amount of their earnings went to vices such as gambling and Smoking. Very little went to health care needs and education.

Health was a priority concern of the people. They would go to great lengths--selling or pawning valuable properties or borrowing money even at usurious rates-just to finance their health needs.

However, much as they value their health, their attitude toward it was more crisis-oriented, curative rather than preventive. They would see a doctor only when they were ill. Seeking health care services was more for children rather than adults. Self-medication was enough for older people. Moreover, perhaps because of poverty, they often did not complete the prescribed dr_lg regimen for their ilh_ess once they felt certain relief.

They expressed more confidence ialthe knowledge and expertise of medical professionals rather than in traditional heaiers or "herbolaryos", who were perceived as the last resort. However, the respondents also expressed preference for private medical facilities and persormel over government ones. They cite the lack of adequate government facilities and the h_competence of government doctors as reasons.

To pay for their medical expenses whichincluded consultations, hospitalization and medicines, the respondents indentified the following sources of funds: their own earnings, donations from relatives or friends, loans from employers, usurers, :relatives or friends, welfare govenu'nent and private agencies, Medicare or health h'lsurance, sale or pawning of properties ' company-p rovided benefits, and other part-time jobs.

Several active organizations had been existing in the communities studied. Bagbag had a neighborhood organization which had been ensuring the continued stay of the residents in the area. On the other hand, Apelo Cruz had a cooperativ e initiated by an NGO which provided medical assistance to the members.

Recognizing the value of a health insurance, the respondents expressed willingness to participate in a health care financing scheme (HCFS) whose terms would be acceptable to them. Among the

32 L

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conditions they wanted met in the event an HCFS would be implemented were: 1. management by a well-organized PO in the community; 2. effective and efficient system of keeping records; 3. regular submission of financial report to the members; 4. monthly share of not less than P5 and not more than P30; and 5. a refund of 50% of the annual share of members if bea_efits are not availed of.

Identified factors which may facilitate the establishrhent and-i_ple.iX-ientation of a health care financing scheme among the urban poor include: the "paluwagan'" system: the people's value of amor propio; people's positive attitudes towards health care, medical doctors and utilization of medical facilities and Medicare or HCFS; their willingness to work for services received; the extended family structure; and existing organizations in the communities whose assistance could be tapped.

On the other, identified factors which may hinder the HCFS's establishment and implementation include: the people's crisis-oriea_tation toward health; misconceptions about rational health care; lack of confidence in government health facilities and persormel; ideological leanings of existing orgmfizations in the community: lack of technical skills and capability of the people; lack of regular source of income; and poor living conditions.

CONCLUSION

i

t is difficult at this point to present a definite structure for a viable health care financing scheme for the urban poor. However, it is Clear in this study that the present efforts of the government, particularly the DOH, which aim to include the urban poor population in its health care program should take into consideration the latter's economic, political, and sociocultural structures.

Perhaps, some of the caveats had already been vocalized by the urban poor themselve_: the system should be "transparent" and clearly understoodby the people themselves and premium payments should be studied carefully beforehand.

While the people had expressed their willhlgn_ess to participate in a health care Fmanch_gscheme, concerned i__dividuals and groups should make sure that such willingness and enthusiam are sustained. Given the limited human and material resources of urban poor communities, existing organizational structures in the communities as well as government and non-government resources should be tapped and maximized to ensure the effectiveness and efficiency of the planned scheme at lesser costs.

On the whole, whatever the final scheme would be, as long as the participation of the people is encouraged in all levels of the plam_xg, implementation, monitoring and evaluation of the said scheme, the chances of success are high.

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ACKNOWLEDGEMENT

We

would

Castillo, staff

like to thank

our

consultants:

Ms. Josie Peti.l.la and Mrs.

members

The research 2 communities

of the_HealthDev was made possible and to them and

Agnes Institute

Mr. Ramon Lagrosa were

L. Sicam,

for their invaluable instrumental

by the cooperation their constituents

Dr. Leonila advice

in the completion

and active participation we are highly indebted.

Dans,

and help.

Mrs.

Nh_a

The other

of this project. of the leaders

in the

_EFERENCES

1. Abad H. Research for whom? Lambatlaya 2: 1o2, 1987.

2. Black M. Philippines: Children of the runaway cities. Manila: Unicef, 1991.

3. Center for CommunitvServices Research Desk. Tl3ePhilippines today, a situational ana;ysis. Quezon City: Center for Social Policy and Public Affairs, Aten_ de Manila University, I991.

4. General Appropriations Act. 1980-1990 5. Click, et el. Integrating qualitative and quantitative survey techniques. Applied research and evaluation.

International Quarterly of Commun!ty Health Education 7: 181-200,5982.

6. Hall BL. Participatory'research;.poputar knowledge and Power. Convergence 14:6-17, 1981.

7. Hardon A. Confronting ill health: medicines, self-care and the urban poor in Manila. Manila: HAIN, 1991.

8. Healthcare Factb0ok 1990 9. Bulan-Lagrosa A. Client-beneficiary analysis financing scheme for factory workers, I991 (ongoing).

10. Philippine Statistical Yearbook, 1990.

11. Ma lanyaon OQ. The pricing of m.edicine,s and i.ts ira _act on the urban poor. Quezon City: Center for Social Policy and Public Affairs, Ateneo tie b'lanila university, 1_6o 12. Ramos-J'irnenez P. Chiong-Javier ME, Seville JC. The Philippine urban situational analysis. Manila: Unicef, 1986.

13. Tan M. Drug needs and utilization patterns in four urban poor communities in Metro Manila. Drug Monitor 28: 1-49, 1988.

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A 'PENDIXA TRA.I2qING MODULE t:OR THE RESEARCH TEAM General Objectives i.

to orient the team members on the principles and practice of participatory conscienfizing research;

2.

to train the interviewers

3.

to provide maintenance mechanisms for monitoring and upgrading of research skills, tactics in getting dependable data, and effective teamwork

on the essential skills in interviewing and in basic communication skills

.,

COMPONENTS: 1.

Two day training seminar

This is a two day seminar focusing on orienting participantrs in participatory research, health care financing and rlsk-sharing, the research design and skills formation in interviewing and documentation.

2.

Weekly tactics sessions

Weekly meetings with the interviewers are Bacilitated by'research staff to assess problems and difficulties encountered in the research and to come out with resolutions and strategic plans.

3.

Post-workshop

evaluation sessions

As a matter of policy, every major research activity participated in by the staff, the research team or the community must be pursued by evalfia'tion and reflection sessions. These will be documented and analyzed for planning purposes.

TWO-DAY TRAINING SEMINAR FOR IaNTERVIEWERS A. Training Objectives 1.

To orient interviewers

on the principles and methods of participatory cons cientizing research.

2.

To sharpen skills in interviewing

3.

4.

To train participants on the basic skills in interpreting and responding to verbal and non-verbal cues To foster effective teamwork and clear task relationships among interviewers and the staff

and communicating

B. I_rogram Schedules Day 1: • Health situationer • Orientation into research design and framework • Communication skills • Process observation

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Day 2: • Group handling • Concept

skills

of research

• Research • Practlcum

skills: focusing

on interviewing

workshop

e. Evaluation

and planning

TIIE MODULES 1.

EXPECTATION

SETTING

A collage of facial expressions is presented on manila paper. Each facial expression denotes an emotion. The participants are then asked to choose which facial expression captures the emotion they feel at the moment.

The facilitator then asks each one to share with the group and explain why.

Emotions that relate to seminar are acknow, ledge and validated.

Mental baggages the staff may provide contingencies just in case these will affect the seminar.

The facilitator then presents objectives of the training seminar expectations and needs will be asnwered by the seminar.

II.

ORIENTATION

A brief overview

m. WORKSHOP:

INTO THE RESEARCH

of the research

ANALYSIS

and participants

are noted as well so that

are asked if the major

DESIGN

desi_,'n is again presented

to the participants

OF THE PHILIPPINE HEALTH

by the overall coordinator.

SITUATION

Objectives: 1.

2.

to maximize the appreciation of health as a social phenomenon and not just a technical problem. to heighten the need for meaningful people's participations in social change.

ActiviD,Proper: A storyis presented

to the group.

The story of Rosario, a child who died of post-measles

bronchopneumonia.

In gist, the story presents the odyssey of an urban poor family in coping with illness in the family. Different social, political, cultural and economic factors came into play and all contributed to the death of Rosario. Each of these factors were specified in the story and became the major factors that caused the child to succumb.

The participants are then asked to point out the different specific factors and to classify them accordingly.

For example, the facilitator will repeatedly ask why Rosario died after each answer the participant can think of. Until he or she cannot think of other related reasons, Hence the answer may be because of malnu trl tion.

The facilitator then asks why of malnutrition. "'Because they are poor," Then why are they poor?

"Because

_

of unemployment

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and low wages."

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Why is there unemployment

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and low wages? .J

"Because of u-njust structures in society." And so on and on. An these answers can be plotted on manila paper encircled inside a ballon and linked to the previous answer by a line. And in the center the question is written "Why did Rosarion die?"

A spider web could be drawn by doing this exercise. And, this is to_highlight how health is inter'woven with other aspects of society that it is actually a social phenomenon.

Synthesis: The participants

are asked to review the web they have created and insights are evoked.

Input on the health indices -- of the top 10 causes of death and morbiditythe participants.

IV.

PROCESS OBSERVATION AND COMMUNICATION

A.

On Non-Verbal Communication

are presented and analyzed by

SKILLS

Objectives: 1.

to highlight the importance of nonverval cues and verval communiation

2.

to practice skills in identifying and analyzing nonverval cues

Activity Proper.

The group is asked to form a tight circle bylocking arms with each other. Each is asked to look at a particular spot which he/she would like to go to. After a moment, they are instructed to convince the whole fgroup to move to the spot without breaking the circle and without making any sound.

Processing: A_ter 20 minutes, the group is then asked to unlock arms and assemble for processing.

Feeling are initially asked. Reactions to the activity are evoked and acknowledged.

After which the group then enumerates the helpful and disruptive behaviors or factors that htey experienced with the exercise.

Synthesis: A summary of learning is made. A short input on the importance of verbal and nonverbal communication follows. (The noverbal cues can help interviewer determine interest or indifference of respondents.)

B. On Listening Objective To sharpen skills in listening by learning to use clariying queations, nonverbal cues and eye contact.

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Activity Proper.

The participants are each asked to recall a memorable experience in their childhood which they would like to share with the group.

After fuve minutes recollecting, triads are formed. The members of each traid are told to decide who among them will share first while _e two_shalll observe. One listener shall observe for the nonverbal cues and the other for content and emotion that it is associated with the content. Each member of the triad will take turn.

And after achsharingsession, feedabckis givenby theiisteners. Theparticipantsaregivenonehour to finish.

Synthesis: In the big group, insights are culled. behavior.

A framework is used to analyze Facilitative and Non-facilitative

C. On Process Observation Objectives: 1. To raise awareness of the importance of process as well as content during group discussions 2. to train simple skills in process observation Activity: Fishbowl observation The group is divided into two groups. A topic of interest is presented for discussion. Group 1 is asked to leave the room. Group 2 is instructed to watch for communication skills, verval and nonverval cues. Each emeber of the group is assigned a person to observe in group 1.

Group I enters and starts discussion.

First Synthesis: The members of group 1 are told about process observation. The overall facilitator first presents an observation of how the discussion flowed. High participators and low participators are noted. Monopoly and other phenomena are pointed out. The members of group 2 present their individual feeback.

Member_

ofgrotW1 are askedforreactions.

In the second half, this time,leadership is basically the same. ' V.

skills are observed by group 1while group 2 discusses. All the rest

WHAT IS RESEARCH?

A simple explanation is given about research. Highlighted is the need for research to be useful and relevant.

It is demystified by showing simple researches already done in other communities.

The different research stages are presented and what constitute each stage

88 VI.

RESEARCH

SKILLS TRAINIG

Objectives: 1.

2.

3,

to level off on what specific skill will be required of the research to develop and practicce skills in interviewing to be aware of the different stages of the interview

Activity

team/interviewers

Proper #1 Input

A lecturette Activity

and review of a hand-out

Proper

#2 Evaluation

on interviewing

of preliminary

will be made. (see Appendix

survey

6)

and role playing

A big group evalaution of the preliminary survey conducted by the research team is handled by the facilitator. Problems encountered were again identified and clarified further. And, suggestions onhow the problems could have been avoided or resolved were evoked.

In a simulation of the problmes encountered, participants were assigned interviewers while selected participants assume problem roles they enumerated, They now try to practice what they have learned.

VII. EVALUATION AND PLANNING

Evaluation course.

of the seminar

and planning

for the coming activities in the community

WEEKLY

TACTICS

end the _vo-day training

SESSIONS

:.

Objectives: 1.

to monitor

the performance

2,

to surface

problems

3,

to process

experiences

of the community

and ventilate

researchers

difficulties

and insights

for resolution

of researchers

and planning.

for deepening.

ActivityProper.

I. A free-flowing

sharing

Sessions of highlights

2.

Positive

experiences

are first highlighted,

3.

negative

experiences

are assessed

4.

Development

5.

Scheduling

the week is facilitated

by the research

if any, and processed_

and ventilation

of plans or contingency and tasking

during

measures

of plans end the session.

of negative

emotions

made for the week.

facilitated.

staff.

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APPENDIX B L_ANGPANANALEKSI_PATUNGOSA PAGPAPA_JPAD NG PROGRAMANGPANGKALUSUGAN PARASA MGA MARALITANGTAGALUNf_DD PANGALAN NG K]NAKAPANAYAM: EDAD" INABOT;

EDUKASYONG

"

PETSA:

ORAS:

1. ]]an ang miyembro Nais namin_

ng inyong pamilya?

tanun_in

2. Sa pangkaranJwan,

kayo tun_kol sagastusin

nmgkano

ang gastos nlnyo sa loob ng isang Iinggo para sa toga sumusunod:

a. pagkain at iba pang bilihin sa palengke b. sabon at iba pang nabibili k pamasahe papunta't d. alak at sigarilyo

sa inyongbahay:

sa grocery,

o talipapa

P

sari-sari store o supermarket

P

pauwi mula sa paaralan/trabaho

p P

e. sine, video, komiks, dyaryo

P

g. togasariling hatol na gamot

P

h. mga gamot para sa toga rnalubhang sakit/matagal 0"talimbawa: alta presyon, diabetes, at iba pa) i. sugal (]ueteng, ending,

p

4, Gaano kadalas ang bayaran? " 'Y

]

p

bingo, at iba pa)

3. Alin pa sa toga sumusunod ang pLnagkakagastusan ninyo?

[

na sakit

Q

5. Magkano bawat bayaran?

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[

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taunan I

,

.

upa sabahay darnit, uniporme

] g. tuition I h. insurance { ] buhay

[ ] [ ]

"y-

L.

]

[

] sasakyan

[

] pangkalusugan

[

] iba pa...

i. l.

butawsakooperatiba ..... gastossapag'papaayos n8 b_hay , .. m, puhunan _a n,egosyoI Q- tuwingik,atlongbuwan ml

M - buwanan

O - {ba pa (pakitukoy) I

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6. PumLli sa mga sumusunod

i

na k_buuang

[ ] 1,0(30 pababa { ] 1,000-1,999

-

"

ml

"

kinikitn ng pan-dlya sa isang buwan

[ ] 3,000 - 3,999 { ] 4,(X)(}pataas

[ ] 2,ooo-2,999 7. Gaa.no ka na katagal

sa kasalukuyang

{ ] Kulang sa taon [ ] Isang mon

[ [

bahay? ] D'alawang taon ] Tatlongtaon

[ lHi,it _ 3taon 8. Lilipat ka ba ng tirahansa susunod na 3 taon?

KALAGAYANG

PANGKALUSUGAN:

9. Sa rtakaraang buwan, mayr_n bang nagkasakit sapamilyapatinarinang toganaoperahan, naaksidente, nanganak,atibapa?

[1oo [ ] Hindi(tumuloysablg34) .....

]

yugto 1

yugm 2

YUStO 3

l-doktor

[ ]

[ ]

[l

2-n_rs

{1

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3-midwife 4-dentista 5-arbolaryo 6-BHW 7 - kamag-anak/kaibigan 8 - walang ikiaunsulta 9-iba pa, pakitukoy

[ ] [ ] [ ] [] [] [] [ ]

[ ] [ ] [ I

[ ] ' [ ] [ }

[1 [l

[1 , [1

[ ] [ ]

[l [ ]

10. Sinu-slno ang toga ito?

11. Ano ang sakit?

12.• Sino a.ng kinunsulta?

13. Saannaganap ang pagpapakonsulta?

(Itukoy) 14. Magkano ang ginastos ni (P) sa pagbiyahe para rruakaabot sapagamutan 15. Magkano

aug ibinayad

ni (P)

P

P

p

sa pagpapakonsulta?

1 - sarilin 8 bulsa 2 - bawas sa suweldo 3 - insurance 4 - u_ng sa kamag-anak/kaibi_an S -nagben_a ng ari-arian 6 - nagsarda 7 - iba pa (pakitukoy)

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y_gto 2

17. Magkano ang mgastos r_ (P) para sa toga g-amot?

18. Kung naospital, anong uri ng ospital?

19. Magkano ar,g nagastos sa pagpapaospital ni

P

P

p

20. Ano ang resulta ng paggamot?

21. Paano ninyo tinustusan ang toga gastossaospital?

1. sariling ipon/pera 2. pagbenta/sanla ng toga aft-arian 3. utang 4. gamot 5. pribadong L_surance 6. tulong mula sa iba 7. iba pang tukoy :

] ] ] ] } ] ]

] ] ] l ] ] ]

] ] ] ] ] l ]

(Dagdagan 11gpapelsa gilid sa ]canonkung may ibapang yugto.) •

yugto 1

yugto 2

22. Anu-anong ari-arian ninyo na ipinagbili/isinanla upang makatulong sa pagtustos sa pagpapaospital?

23. Magkano ninyo ito iplnagbili/ isinanla?

24. Kumikita ba ang mga ari-ariang ito? [

•

1Oo [ I Hindi

[1 [ ]

[1 [I

25. M_gkano ang kinikita nito sa bawat buwan?

P

P

26. Sa lingin ninyo, magkano dapat gng halaga ng inyong ari-arian?

P

P

27. Magkano ang naipangutang ninyo upang idagdag sa pagtustos sa pagpapaospital?

P

P

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28. Kani-kankao kayo nangutang ng pera?

--

1.

2.

3.

4.

5.

6.

bangko amo/may-aringpinapasukan utangsa5-6 kama$-ar_k kapit-bahay/kaibigan ibapangtukuyin

{ [ [ [ [ [

] ] l ] ] ]

[ [ [ [ [ [

l ] ] ] ] ]

29. Gaano katagal ang pagbabayad ng inutang ninyong pera?

30. Magkano ang interes/tubo inutang ninyo pera?

ng

31. Nag-iwan ba kayo ng "prerada" para maka-utang ng pera?

32. Magkano ang halagang nakuha ninyo mula sa MEDICARE para sa pagpapa-ospital?

P

P

33. Magkano ang halagang nakuha ninyo mula sa "insurance" para sa pag-papaospital? _ ..

P

P

Talakayin hating ngayon ang t_mgkol sa iba't-ibang sistema na kung saan ang isang indibidual ay nagbabayad para sa pangangailangang pangkalusugan. Ang isang pinakakilalang mekanismo ay suportang ibinibigay ng medicare para sa toga SSS/GSIS. 34, Mayroon ba sa inyong pamilya ang miyembro ng medicare?

[ ] (3o (Sagutan Big. 40-52) [ ] Hindi

35. Mayroong toga ibang tao na sumasali/naghuhulogsa pribadong "insurance" or HMO? Mayroon ba sa inyong pamilya ang kasapi sa ganitong sistema o HMO.

[ ] Oo [ ] Hindi

36. Mayronn din namang iba na binibigyan ng toga bet-tepisyong pangkalusugan ng toga kompanyang kanilang pinapa sukan. Sa inyo bang pamilya ay may nakararanas ng ganitong benepisyo?

[ ] Oo [ ] Hindt

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37. Ikaw ba o sinuman sa inyong pamilya ay kasapi ng isang kooperatibang pangkalusugan na susuporta sa toga gastusing pangkalusugan?

[ "10o (Sagutin Big. 66-76) [ ] Hindi

38. Sakaling may naospit_il o nagpakonsulta ang sino man sa inyong pamilya, may-coon ba kayong tukoy na tlao/grupo na maari ninyong lapitan upang hingan ng tulong?

[ [ a. b. k. d. e.

] (3o, tukuyin ] Hindi rnagulang, kapatid dvic group (tukuyin) kaibigan kamag-anak iba pang tukuyin

39. Anong uri ng tulong/suporta ang maibibigay ng taong ito/ grupo sa inyong pamilya? a. pera, libre b. pera, utang k. assistance in kind I.IPARA SA MAY MGA

MEDICARE •

Kasapi 1

Kasapi 2

40. Ilan sa inyong pamilya an nagbabayad sa Medicare bilang miyembro?

41. Sinu-sino ang mga ito?

42. Mayroon bang miyembro ng SSS/GSIS sa inyong parrtilya?

43. Gaano na katagal kasapi siya/sila ng Medicare?

44. Mayroon na ba sa inyong pamilya ang na-ospital at nagamit ang toga benepisyong mula sa Medicare?

Oo

Hindi

Bakit hindi?

Kasapi 1

Kasapi 2

45. Sinu-sino ang toga ito?

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46. Gaano kadalas ninyo nag_rnit ang g-anitong benepisyo?

47. Kailan ang pinakahuling pagkakataong nagamit ninyo ang Medic_e para sa pag-papa-ospital?

48. Mula sa pinakahuling pagkakat'aong ginamit ninyo ang Medicare, mayroon ba kayong puna tungkol dlto?

[ ] Oo [ ] Hindi

49. Anu-ano ang toga punang ito: (Lagyan ng check) [ ] Maliit ng porsiyento lamang [ ] Matagal ang pag-aayos ng toga papeles para sa Medicare Iba pang tukoy [ ] Hindi alam kung paano ang pamarnaraan ng paggamit ng Medicare 50. Sa inyong palagay, makatutulong ba ako sa toga tao ang maghulog sa Medicare, kahit hindi pa sila na-oospital? Bakit?

[ ] (3o [ ] Hindi

51. Mayroon ba sa kasalukuyang programa ng Medicare na nais ninyong linawin o baguhin?

[ ] Oo [ ] Hindi

52. Anong toga konkretong pagbabagong nais ninyong gawln para sa toga sumusunod na aspeto?

Mungkahi ng Pagbabago

[ ] toga benepisyo [ ] prosesong dinaraanan/ginagawa [ ] premiun_ [ ] mg-a sffmsakop/shnasagot [ ] legal na pamamaraan 1.2 PARA SA MAY PRIVATE II'_S_CE,

HMO, KUNG WALA TUMULOY SA BLG. 66

53. Ano ang pangalan ng kompanya i_a nagbibigay sa inyo ng toga prebilihedong pangkalusugan o sumasagot sa inyong pangangaLlangang pangkalusugan?

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54. SLnu-smo _g l_qepisya_o _g ganitong "Health Insurance"? [

]

direktangmanggagawa/miyembro

[

]

direktang-miyembm

[

]

lahat ng dependeyente

at angkanyang

asawa

(mkoy na bilang)

[ ] iba pangtukoy 55. Magkano ang ibinibigay na hul0g ng miyembro at ng amo [ ] premlum na hulogng direktang miyembro

P

[

P

] premium na hulogngamo/ sponsor ] di alam

[

56. Ano ang pang-alan ng amo na plnapasukan ng miyembro?

57. Anu-ano toga serbisyong kalusugan ang iblnibigay inyong "Health Plan"

pangng

[

l simsagot_ng g,_stos s_ ospital, toga gamot, dokŠr

[

] iba pangtukoy

[

] dialam

58. Mayroon bang limitasyon ang toga serbisyong pangkalusugang ibinibigay?

59. Anong uri ng benepisyo

[ ]

Oo

[ ]

Hindl

ang kanyang nagamit?

[

]

oubpafient

[

]

in-pal_ent

[

]

u_ang pang-medika[

[

l

dental

[

]

para sa salamin pa:a sa mata/optical

[

]

panganganak

[

]

reseta o prescription

r_'_gamit o medical loan

o maternity

60. Magkano ang nagastos sariling pera?

mula sa

61. Gaano katagal na kayong kasapi sa ganitong uri ng sistema?

62. Ano sa tingin n.inyo ang maganda/sulit sa ganitong sistema?

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63, Ano sa ti_gin ninyo ang di n_ganda/di sulit sa g'e, nitong sistema?-

64. Paano kayo naging kasapi sa ganitong sistema?(healthplan) [ I ku._ [ ] sapinagtatrabahuan 1.3SA2v[AHANG

KINASASAPITAN

66. Anong uri ng samahan

kayo kasali?

[

]

samahan sa simbah_n

[ [

] ]

samahansa PO/NCO

[

l

ibapangtukoy

loobngkomumdad

67. Saan itorrmtatagpuan? [

]

saloobngbarangay

[ ] iba't ibangbarangaysubalit parehonglunsod [ ] iba't ibang bayan subalit parehon8 probinsiya [ ] iba'tibangprobinsiya 68. Saan nanggagalingang pondo ng inyongsamahan?

69. Ang inyobang samahan ay nakikisangkot sa iba't ibang gawain n_libansa kalusugan?

[ ] Oo

[ ] Hindi

70. Anu-anong togagawain patungkolsakalusugan ang kinikilusan ng inyongsamahan?

71. Gaano na katagal kayong kasapi sa samahan?

72. Ano ang paraan ng pagbabayad?

.bu]uw n8 kasapi diskuwento suyuan / bayanihan iba pa,ituloy

73. Sa anong dal'd[a_ kayo sumali sa inyong samahan?

74. I<_ilan ang hullng pagkaka taon na ang miyembro [ l na'karaangbuwan [

]

ng inyong pamilyaay

nakagamit

ng ganitong beneplsyo?

sa loobng:3 buwan pero mahigit na isan$ buwan

75. Kailangan bang mag-ipon

ng pera para sa toga emer_..ncy o dagIiang pang_gailangml?

[ .] Oo [ ]

Hindi I

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76. Kusag kayang gawha ito, anong uri ng toga dagliang pangangaflangan (Atasan ng rang, go, 1 bilang pkmka.maha]ag-a) [ ] Para sa eskuwela ng mga bata [ ] Pang-tetiremant [ ] Bahayal:lupa ( 1 Para sa kalusugan [ ] Para sa pagkain [ ] Iba pa (Pak_tukoy)

ang tatabihan mo ng pera?

77. Kung hihbagan ka ng butaw, para saan mo gusto itabi ito?

(Paki-atasan ng ranggo, bhang 1 ang pinakamahalaga) [ ] aksidente/kalamidad/sakuna [ ] pangkabuuangpag-aalaga ngkalusugan [ ] adukasyongpang-kolahiyo 78. Saan mo kukunh_ ang pera pare dito?

(Tukuyin ang lahat na pagkukuhanan too) [ ] suweldo [ ] regalo [ ] tulongnggobyemo [ ] plmgsasama ang lahat n8 kita [ ] remittance [ ] ibapa(pakitukoy) 79. Ktmg saka-sakal_ng [ ] mga naipon

may biglang ma-ospital

sa parnilya mo, saan mo kukunin ang pangtustos

dko?

[ ] utang [ [ [

] masbentongari-arian ] pagsangla ng gamito ad-arian ] ibapa (pakitukoy)

ATTITUDES.

PERCEPTIONS,

A.

ng Kalusuga.n

Komepto

g toga pangu_gusap.

PRA, .CTICES

Nung mng-ayon _, sumagot ng

_

. r,,ung hindi haman pakisabmg Oo

B.

Hindi

>

Ang _ong malusog ay isang tao na b.indi nagkakasakit ng mahabang panahon.

[

]

[

]

>

Kumukunsulta lamangsa doktor kap-_g may karamdaman ha.

[

]

[

I

>

Pareho an 8 toga probleman$ par_gkalusugan ng toga mayayaman at mahihirap.

[

]

[

]

AngPangkalusugang

Manggagawa

>

Laging tama ang herbolaryo pagdathag sa kalusugan

[

l

[

]

>

Laging tama ang doktor pagdati_g sa kalusugan.

[

]

[

]

[

]

[

]

C. Uri ng serbisyong pangkalusugan >

sa amin 8 pamayanan.

Sapat ang mga serbisyong pangkalusugan sa aming pamayanan.

"Hmdi .

48 Oo

Hindi

>

Kasing husay ng mga doktorsa gobyemo ang toga doktor sa pfibado.

[

]

[

]

>

Pantay-pantay ang pa_gngin ng pribadong doktor sa kanyang mga pasyemte.

[

]

[

]

D. Camit ns Serbisyong Pangkalusugan >

Kung pareho ang sing[fan sa ospital ng gobyemo atsapribado, higit kong t_tangkilikm ang pribadong ospRaL

[

]

[

]

>

Kahit mahusay naman ang pribadong ospital ngunit mahal, mas gugustuhin ko pang pumtmta sa ospital ng gobyemo dahil sa mura.

[

]

[

]

>

Kung malubha ang _kR ng isang taong may edad, dadalhin kaagad siya ospital klinika/ospital ng gobyemo kaysa sa pribadong klinika o ospital.

[

l

[

]

>

Kuns malubha ang sakit ngisang taong may eclad, dadalhinko siya sa klirtika/ospital ng gobyemo kaysa sa pribadong klinika o ospital.

[

]

[

]

>

Interesado ba kayong lumahok sa isangsistemang tutustos m toga gastuskng pangkalusugan.

[

]

[

]

>

Papayag ba kayong magbigay ng regular rm butas (buwanan o lingguhan) para sapanmstos ng toga pangangailangang pangkalusugan?

[

]

[

l

I:: Drugsand Pres:fiption

. . .

>

Kung mukhang malubha ang sakit ng isang tao, dapat lamang ma grectang gamot angdoktorkung mahusay siya.

[

]

[

]

>

Kung gumaling ang isang pasyente, maaari nang itigil ang pag-inom ng gamot kant na hindi pa ubos ang naire_ta.

[

]

{

]

>

Maaring gamitin ang da fihang nairesemng gamot para sa isang _kit rm kamukha ng dating _kit na gumming ha.

[

]

[

]

>

Dapat lamang uminom kaagad ng antibiotics kapag may k_ramdaman.

[

]

[

]

Jll

iL

......

iii

49

APPENDIX C

FOCUS GROUP

DISCUSSION DATA

PROCESSES RIfLES/GUIDELINES L

OBJECTIVES: 1.

2.

3.

To assess present health needs, preferences and attitudes in health seeking towards sharing risk in health financing; To evoke possible problem areas or conflict in the implementation of a health care financing scheme in the community; To identify possible community institutions or mechanisms that may facilitate the putting up of health care financing;

II. GUIDELINES:

III.

A.

Discussion g_Hdelines:

1.

Participants numbering 10-15 must be either the mother or father of the family in the target communities and some leaders in the community.

2.

The discussion is free-flowing and everyone must be able toair their opinions and should conflicts arise -- the basis of conflict must be identified and expressed. There is no need to resolve the conflict.

3.

The discussion must be do¢'umented by a tape recorder and/or a documentor.

4.

The process will take one to one hour and a half.

B.

Guide questions:

1.

2.

What health services do you require in the community? and how do you access them at present?

What do you understand by cooperative7

3.

What do you think of this type of financing?

4.

Do you think this system of health care financing will succeed in the community? think so? Why not? What mechanisms do you suggest to ensure success?

Why do you

SYNTHESIS OF FOCUS GROUP DISCUSSIONS: Six focus group discussions were held in the communities with an average of 10-15 participants per group. 67 people participated and majority are women.

A.

Attitudes

on health and Hsk-shaHng:

Discussions on risk-sharing got impeded by discussions of mechanisms and operations of risksharing. A discussion of what risk-sharing means had to be done first to clarify what risk-sharing is and what Medicare does. Hand-outs were distributed and discussions of the informal type were held in the communities. Then the focus group discussions were again conducted.

However, most discussants admit they have to consult their husbands first since most of the participants were married women. Even if the fee were P1/day, their husbands had to be consulted. x

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Only if the fee were P5/month then no discussion with their husbands is necessary. One participant, a woman of 40 who smokes 10sticks of cigarettes a day, said that she can pay P5/day -- all she had to do was reduce her smoking to half. But majority agreed that P20/month would be the most reasonable.

Discussions of cost of medical care revealed that the poor were paying exorbitant doctors' fees.

One consultation would cost P200 at the very least. This, however, would include the drugs which are only available in the adjacent doctors' drugstore. In one instance, a participant who is a flee-lance -carpenter, reported spending P400 for the drainage of abcess in a government hospital. This includes cost of drugs, gloves and even the anesthetic agent which he claims did not work.

Another mother spent P2,000 just for drugs in Jose Reyes Memorial Medical Center for a twoweek stay of her seven-month old baby who was sick of pneumonia. Consequently, this mother was hoping they could enjoy Medicare benefits, even just for the children.

B.

Attita_d_s towards Medicare

After one focus group discussion that included a discussion of Medicare, the staff realized that little is known of Medicare by the people. Only a handful of the participants knew and are currently enjoying benefits from Medicare through their husbands who are mostly factory workers. The staff has to intervene by holding orientation sessions on Medicare and distributing leaflets on Medicare.

After the education campaign on Medicare, the focus group discussions were resumed. For people who were covered by Medicare, their experiences withMedicare were generally positive except for the usual complaint of red tape. For those not covered, Medicare enjoys a very credible status. But everyone agreed that the system could use more improvements especially in the area of amount of benefits. Another consensus suggestion was to include out-patient care. Discussion ended with a guarded note on how Medicare can cover the urban poor. The people were concerned about the monthlyd ues that will be collected and the mechanism of collection. In the end, most of the participants admitted that there must be a genuine organization in the community who can facilitate the collection and the coordination with government institutions who will handle such a health care financing project t

C.

Some insights on the health financing project:

Discussion of how sourcing of financial expenses was severely limited by the fact that the people were too embarassed to talk about this in a group. Follow-up and pryingquestions were ignored. Later on, lack of integration of the staff since the focus group discussions were handled early on in the research was spotted as one factor for this limitation.

D.

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Suggestions from the groups: 1.

Many were willing to pay the government health centers of even up tp 50% of costs of medication as long as the drugs are of good quality and of adequate supply.

2.

Hospitalization

3.

Most par ticipants prefer to go to the private doctors since they are considered better doctors and they have drugs available in their clinics. As a matter of fact, patients who go to the government health centers go there only for the minor ailments like cough and colds. For ntore serious conditions, they go to the private doctor and later to the government hospitals.

....

subsidy by Medicare should be increased to 50% of total hospital cost.

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4.

Patients claim that the government health centers are weak because of two things: patronage system-- you are better taken cared of and more quickly ifyou know and offer favors to the health center personnel. lack of drugs -- patients cannot afford the drugs prescribed by the government health physicians-pa tients cite cost of travel and time consumed just to get to another drugstore for the purchase of an expensive drug.

5.

Jl;

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Observation

i

of facilitators and staff:

a.

doctor-dependency

even for the minor ailments prevail

b.

irritational drug use abounds as antibiotics are taken even for viral conditions and ' prescriptions are never completed

c.

health care seems to be a major concern of the community especially the mothers

d.

security of land tenure though it did not come out in the discussion is a major concern in the community since flu-eats of demolition were hurled at them months before the research started and many say that this would depend on the outcome of the elections

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"SPECIAL

COMMENTS ON THE STUDY BENEFICIARY GROUP: THE URBAN By: Mario M. Taguiwalo _ _anuary13,1994

POOR"

The study of Dr. Olympia Q. Malanyaon is a useful decription of the socio-economic conditions that frame .... the urban poor's possible participation in a health care financing scheme. My comments are of the nature of speculations about the meanings and implications of the study's findings.

I.

The study presents a picture of individuals, families and communities living on the edge, literally on the edge of inhabitable land, and figuratively on the edge of dignified existence. They are relatively young (hence low levels of accumulated assets); mostly recent migrants (hence separated from their extended family networks); lack security in housing and employment (hence uncertain physical and economic conditions); operating in chronic financial deficit for ordinary living needs (hence probably in continuous debt).

It seems to me that these conditions, their behavior relative to health is rational and sound. They only act in the face of a health crisis because there are many more important needs to their survival other than setting aside money for a health emergency. As it is they are already in regular deficit and may already be in debt for their ordina D, daily needs. They use the community and government as a substitute for the informal family support network which could have been lost upon their migration to the city. These ne_vorks normally respond only in a crisis. They use curative and private fadlities because the conditions they face during these crises require such capabilities. And they resort to expensive emergency financing "_m order to pay for these crises because theyhave probably utilized their regular sources of financing for their non-crisis needs.

2.

Can we make the case for more efficient, more appropriate financing beahavior under their conditions?

Illness is the crisis which the poor regularly meet. Financing the services and goods required to adequately address illness is the challenge that has to be met. In order to sort this out, we could make a distinction between illness that occurs as a random event (e.g., accident, unavoidable cancer, violence, hereditary conditions); and illness that occurs as a logical consequence of lifestyle (e.g., malnutrition, communicable diseases due to poor sanitation, preventable illnesses). Financing personal medical ca re for the first group of illnesses makes insurance or risk poolingsense because people cannot predict these things and therefore they need to set aside contingent funds for them. Financing personal medical care for the second group of illnesses should be better approached form a public health. Not an insurance standpoint. Instead of setting aside money for a possible hospitalization due to measles, it may make more sense spending money to obtain measles immunization. Instead of cracking our heads looking for ways to finance the treatment of diarrhea, measles, tuberculosis and other communicable and preventable diseases, we should instead focus on altering the known and prevent risk factors of these diseases through better nutrition, health education, household practices, early treatment and cure; measures better undertaken as direct public health interventions rather than services extended via health insurance.

t ProjectDirector. UPecon-HealthPolicyDevelopmentProgram

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COMMENTSOF THE STUDY"SPECIALBENEFICIARYGROUP:TIlE URBANPOOR" __ By:Mario M. Taguiwalo _anuary 13,1994

pate 2 The point is that under the conditions of extremely adverse public health conditions of the urban poor, community financing and local health inst_rance could be a solution looking at the wrong problem. The proper response is vigorous, well funded, effective and wide coverage public health programs, financed by tax money and undertaken by health service institutions whose provisions are subsidized.

Once these are in place, it then makes sense to plan and undertake risk pooled, par ticipatorily financed, personal care programs for the illnesses that occur even with the systematic improvement of public health measures.

3.

The study documents the availability of health facilities in the activity of the urban poor communities.

This is an advantage which the rural poor does not have. But the study also indicates how unresponsive these facilities are to the health needs of the urban poor. Both private and government facilities are indicated. There is no lack of facilities but there is clearly a lack of purchasing power on the part of the urban poor, hence their lack of influence on the operational priorities of these facilities.This to me points to the possibility of converting government subsidies for the health needs of the urban poor, from subsidies to facilities into subsidies to poor consumers utilizing facilities. A system where the poor are entitled to buy health service vouchers at less than their face value, which can then be used for professional services, medicines, hospitalizations and other health services from designated facilities could be a measure to combine government subsidy with people's own contribution so that the poor can buy satisfactory service.

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